A couple of weeks ago, there was wide coverage in the print media about a successful pregnancy outcome in a 60-year-old woman in a fertility clinic in Tamil Nadu. The triumph of technology over natural barriers, be it in the field of medicine, science, environment and so on, undoubtedly gives a sense of achievement and satisfaction to all scientists, especially when such innovations are productive to mankind. However, every invention has its pros and cons, and it is more so in the field of fertility medicine as it involves complex human relationships. The picture of a 60-year-old mother holding a newborn conceived from a donor oocyte does raise a few concerns.
In India, nearly 15 per cent of all married couples in the child-bearing age (about 15 million of them) are infertile, and the management of the condition ranges from sex education, weight loss and medication to advanced assisted reproductive techniques (ART). The rapid evolution of newer technologies in assisted reproduction has given an opportunity for older women to achieve motherhood, but this has also spawned new ethical concerns. Parenthood at an older age is not just a medical issue but a complex, psycho-social issue. The rates of medical and surgical complications are much higher in older women both during fertility treatment and pregnancy. The maternal mortality rate in pregnant women who are 45 and above is high because complications such as hypertension, diabetes mellitus, haemorrhage, pre-term delivery, stillbirth, and caesarean section delivery are three to four times more among them than among younger counterparts.
The second issue is the use of donor oocytes in ART. The average life expectancy of an Indian is 64.4 years: among men it is 63 years and among women it is 66 years. This fact points to the risk of a child born to parents beyond a certain age becoming orphaned. Studies have revealed that the incidence of growth retardation, learning disabilities and behavioural disorders is higher in children following the death of their mothers, or their being orphaned during early childhood. The Central Adoption and Resource Agency based in New Delhi has set down clear guidelines on the age limit for adoptive parents and adopted children. In order to be able to adopt a child less than one year in age, the composite age of the adoptive parents should be 90 years and neither parent must be older than 45. The parents' age is relaxed in accordance with the age of the child — for a one-year-old it should be 46 years, for a two-year-old it should be 47 years, and so on, with the upper age limit of the child being 12 years and that of the parents 55. Fertility clinics should discuss and encourage adoption among older women instead of exposing them to serious risks involved both during treatment and pregnancy. Therefore, a public debate is required to create awareness about the ethical issues involved.
Draft on ART
The Union Ministry of Health and Family Welfare, working with a group of experts, formulated a draft on assisted reproductive techniques in 2010. It is comprehensive with effective guidelines and protocols that would enable standardised, qualitative safe practice methods within the legal framework. However, a consensus has to be created on issues such as the upper age limit for fertility treatment, donor anonymity, the rights of the child, guidelines on publicity and advertising, and the availability of health insurance. The draft suggests that the disclosure of the donor's identity to the recipient couple or individual or to anyone else be made a punishable offence.
In the United Kingdom, the Human Fertility and Embryology Authority (HEFA) created under an Act in 1990, removed the donor anonymity clause in 2005. This was based on the rationale that at the age of 18 a person has the right to know about the origin of his or her birth. The cultural values and attitudes in India may be different from those in the U.K. However, the formation of social attitudes is an evolutionary process. Therefore, two decades from now donor anonymity may well become unnecessary.
Need for a central repository
In order to equip ourselves for the future, the creation of a central repository of information on all donors should be considered. HEFA does not allow women above 45 years of age to be recipients of donor oocytes. The American Society of Reproductive Medicine recommends a thorough medical examination and a high-risk obstetric consultation for all women above 45 years of age receiving donor oocytes. And, in order to undergo ART they need to get cleared by a peer review committee.
At present the number of donor oocyte recipients may be only a few thousands in India. But an increase in female literacy could encourage women to focus on their careers, use methods of contraception on a wider scale, and marry late. These factors could alter the reproductive epidemiology in India as in the western world. The optimum child-bearing period is between 20 and 35 years, and nearly 85 per cent of the women in this group will conceive naturally. Difficulty to conceive and the risk of miscarriage increase after 35 years of age. The success rate of live births following in vitro fertilisation (IVF) treatment even for women below 35 years of age is 31 per cent, and this rate drops to less than five per cent in women over 42 years of age. Therefore, it is important to create awareness among the public on the issues surrounding late motherhood.
Article 16 of the United Nations Declaration of Human Rights (1948) indicates that “men and women of full age, without limits due to race, nationality or religion, have the right to found a family.” India is no longer in the league of poor nations, yet it is a country of paradoxes: it has one of the highest maternal mortality rates in the world and a very high incidence of infertility. Therefore, there is an urgent need to take a wider consensus on the draft on assisted reproductive techniques and to convert it into a cohesive regulatory Act for the ethical implementation of ART. The fundamental aim of such an Act should be to ensure that the basic human right “to found a family” should be achieved by voluntary means, and not through coercion, or the wilful display of the wide array of newer reproductive choices that are available.
( The author, a practising obstetrician and gynaecologist, is a former Tamil Nadu Minister. E-mail: firstname.lastname@example.org )
A public debate is required to create awareness of the ethical issues involved in fertility treatment procedures.